Claims Annual Report of Income Form

One month prior to the anniversary date of an award for unscheduled permanent disability benefits, the insurance carrier or self-insured employer will send a Workers’ Annual Report of Income form (Form 110-A) to the Injured worker or authorized representative.  This form must be completed and promptly returned to the carrier or self-insured employer.

This form is made available for use on this website but is not filed with the Commission.  Carefully follow the directions on the form and return it as instructed.

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.